Nursing is a profession accountable to society for providing high quality cost-effective care for patients and their families (Burns & Grove, 2007). This assignment will define evidence based practice and its significance in the nursing process. In addition, it will critically analyse the research article ‘Community Psychiatric Nurses’ experience of working with people who engage in deliberate self harm carried out by Thompson et al (2008). Furthermore it will define Hierarchy of Evidence and its importance in research studies. A clinical question has been formulated using Population, Intervention, Comparison and Outcome (PICO) and the key words in the article to search for another article which support or contradicts the main review article.
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Brown defines evidence based practices as the use of the best quality research to deliver an effective quality of care in the best interest of the patient as well as promoting cost effectiveness within the healthcare system (Brown, 1999). In order for health care professionals to deliver the best quality of care, they need to use the combination of evidence based clinical treatments and practices (Lindsay, 2007).
Evidence based knowledge is important as it guides and maintains the clinical competencies of health care practitioners and provides a research based explanations to assist patients in the process of clinical decision making (Burns and Grove, 2007). According to Ciliska et al (2005), the skills necessary to provide evidence based solution to a clinical dilemma includes defining the problem, conducting the effective research to locate the best evidence, critically appraising the evidence and considering that evidence and its implications in the context of patients’ circumstances and values.
Research into the experience of community psychiatric nurses working with people who engage in deliberate self-harm was carried out using the qualitative research design, as it is primarily concerned with understanding human beings experiences in a humanistic, interpretive approach (Ronald et al, 2007). The purpose of the research was to understand CPNs’ experience while they are working with people who deliberately self-harm. In this research it was found suitable as it relies less on non numerical data.
A study by Playle (2000) suggest that readers need to read, critically study and evaluate a research article to demonstrate their understanding of research and to identify implications for practice. In this study, Tarling and Crofts (2002)’s framework and The Critical Appraisal Skill Programme (CASP) accessed on http://www.phru.nhs.uk/Pages/PHD/CASP.htm has been used to review the strength, credibility, validity and weakness of the above study.
The title “Community Psychiatric nurses’ experience of working with people who deliberately self-harm is clear, concise and informative as it reflects the contents of the whole study. Informative titles are important in research process as it allows the reader to identify the research approach (Roe and Webb, 1999), however the title does not reveal the approach which may be seen as a weakness (Dempsey and Dempsey, 2000).
The authors of this article are qualified professional with clinical and psychological expertise as well as experience of working with people with mental health problems as Dempsey and Dempsey (2000) suggests that authors should be qualified to carry out a research study and their qualifications should be verified if need be. This may be seen as powerful, hence reliability and credibility of this article is not questionable as they will be perceived as professionals with clinical credibility to eliminate bias (Hoskins et al, 2005). However it can be argued that the community psychiatric nurses had not undertaken psychotherapy training although they had a minimum of eighteen years of experience (Thompson et al, 2008).
The abstract is short, brief and concise. According to Parahoo (2006) a research report should begin with an abstract which summarises the major findings of the study as well as attracting the reader’s attention to read the whole research article thus adding credibility and validity to the report. Lack of clear summary may be seen as a weakness as readers may lose interest in reading the whole article as it may fail to express the important information about the study (Morrison, 1992).
According to Newell & Burnard (2006), an introduction should clearly define the key words and stating the purpose of the research. This study clearly explains in detail what is meant by deliberate self-harm and yet there is little research into the actual experience of working with people who deliberate self-harm (Thompson et al, 2008).
The research used Interpretative Phenomenological Analysis (IPA), which allowed an in-depth exploration of individual personal experience, underpinning the theory of interpretation and interaction which focuses on individual’s experiences to the central concern and can only be accessed through IPA (Smith, 1995). According to Streubert and Carpenter (1995), Interpretative is the “understanding of life experiences and events” and Phenomenology is the “appearance of things as lived experiences”. This may be seen as strength as it is fundamentally important, as without knowing exactly how the study was carried out, it is difficult for the reader to judge its strengths and weaknesses (Gillis, 2002). In this study, the researchers and the participants were all from the North of England thereby eliminating the theory of ethnography which requires the investigator to learn about a culture and be part of it (Burns and Grove, 2007). The participants were made up of four male and four females from the community mental health teams who had an average age of forty years and eighteen years of experience of working with people who engage in deliberate self -harm. The researcher did not explain why different age groups did not participate or other ethnic minority groups which limited their findings.
For the purpose of this study, a purposive (participants with a specific characteristics (Lindsay, 2007) sample was recruited. According to Parahoo (2006), sampling is important in qualitative research as it seeks to collect valid and reliable data from a small division of the population that would be representative of the whole population. This showed to be suitable to the study which may be seen as reliable and valid although, it can be argued that sampling method may produce biased results. It may be seen as a selective method to fulfil the aims of the study (Streubert-Speziale & Carpenter, 2007).
Data was collected through semi-structured interview and open-ended questionnaires according to IPA (Smith, 1995). The interviews lasted for forty five minutes to an hour which was guided but did not dictate the exact course of the interview. This was chosen in order to allow the interviewees to talk freely to explain their thoughts and experiences. The method accessed the participants’ natural attitudes and understanding of deliberate self harm. This enabled certain responses to be questioned in greater depth, while collecting similar data from all the informants as well as creating a relaxed comfortable environment for the interviewees, (Holloway and Wheeler, 2002).
However it can be argued that it is a time-consuming method, not just the collecting of the data, but the transcribing and analysis of the data. There are risks of interviewer bias as face to face interviews often require training, (Parahoo, 2006).
All interviews were recorded and transcribed verbatim. According to Holloway and Wheeler (2002), “researchers must preserve participants’ words as accurately as possible before analysing the data”. The researchers had a chance to replay the tapes several times to improve the quality of the transcripts.
The transcripts were then analysed using IPA principals (Smith and Osborn, 2003). The researcher read the transcripts to familiarise with the data, noting down the key words and phrases said by the participants, thus summarising the sample (Rowntree, 1991). The notes were classified in more general term to form initial themes to try and capture the essence of the participant’s accounts which were then copied to a computer program which assisted in managing connections between the emerging themes but no direct analysis was made.
According to Morse and Field (2007), transcripts from different informants should be compared categorised and coded into substantive themes and sub-themes to produce a high degree of interpretation and integration. A master list of themes and subthemes was then produced for transcript which contained a degree of interpretation and integration. The process was repeated on every interview to maintain consistence of data analysis as suggested by Burns and Grove (2007). The themes were highly developed and compared to original text as Speziale Streubert and Carpenter (2007) suggests that researchers needs to move forward and backward between levels until saturation is achieved to ensure a comprehensive understanding of the phenomena.
A table was produced for each theme indicating the sub themes and identifying where each transcript could be evidenced. Different methods were employed to ensure trustworthiness and the master themes audited by the three authors including an independent researcher to ensure that themes were warrantable and grounded in the data.
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Although the researchers have carefully considered how to ensure validity of the study, it is noted that the findings were subject to limitations as all the nurses were experienced white British, limiting the applicability of nurses from other ethnic origins or trained in other countries. In addition, it is a small study based in a small geographical area which limits reliability as well as the generalizability of the results (Meadows, 2004).
There is also evidence that there may be differences in assessment practices between different professional groups and different levels of experience, (Weston, 2003). Furthermore, the findings are based on reflective accounts of the experience of working with patients, who self-harm and may therefore be subject to memory bias, (Thompson et al, 2008). The authors recommends further studies to explore the extent of experiences and evaluate further interventions to improve professional awareness of deliberate self-harm as well as training for nurses to provide high standards of care as suggested by NMC (2008).
The researcher sought approval from the NHS (National Health Service) ethical and research government as suggested by Parahoo (2006) thus adding credibility. However the research does not specify if consent, was sort from the participants which may appear as a weakness as it important to respect for autonomy and beneficence (Polit and Beck, 2006). Ensuring of confidentiality NHS (2008) of information discussed, was not addressed to the participants before the research was carried out which may have led to withholding of important information which would affect the validity of the report (Clifford, 1997). This can be seen as a weakness in the research.
Hierarchy of evidence is the ranking of research methods according to their effectiveness, strength and weaknesses (Ciliska et al, 2005). In the healthcare system, depending on its source, some research methods are considered to be stronger and produce better quality evidence than others hence credibility, reliability and validity differs (Lindsay, 2007). According to Polit & Beck (2008), qualitative research falls on level V because of its systematic descriptive of psychological studies
Craig and Smyth (2002) suggests the use of PICO (systematic way to identify important ideas in a research article), in formulating a clinical question in health care.
P is Population which was Deliberate Self harm
I is Intervention which was Not Applicable
C is Comparison which was Not Applicable
O is Outcome which was CPN experience.
To search for the second article clinical question has been formulated using PICO. The following link was used to access the article.
Student Portal Log In my studies summon type in key words Go Button.
The search was carried out using the key words, ‘CPN’s experience in deliberate self harm in all fields and 310 articles were retrieved. The search was limited to product content journals only which retrieved 306 journals. The search was further limited with the number of years from 2009 to 2010 which yielded 35 journals articles. Among the articles, ‘Analysis of Accident and Emergency Doctors’ Response To Treating People Who Self-Harm’ was retrieved and read through which supported the reviewed article adding to its strength, validity and credibility. A study by Craig & Smythe (2002) suggests the search of electronic database as a method of finding research studies as all journals have indexes that have been converted to electronic databases. The University subscribe to Summon which can be accessed freely by all students which makes it easier to search articles for educational purposes.
In conclusion, evidence based knowledge is important in implementation of cost effective nursing intervention and therefore it is the responsibility of health care professionals to critically analyse any piece of evidence for credibility, validity, reliability and its source, in clinical decision making (Brown ,1999). They also have a legal and professional responsibility under the Human Rights Act 1998, Health and Safety 1974, The Consumer Protection 1987 as well as The Duty of Care (NMC 2008).
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